Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States (U.S.) and India. To improve outcomes after severe TBI, evidence based U.S. Guidelines for the Acute Medical Management of Severe TBI were published in 2007. However, studies suggest that hospital adoption of evidence based guidelines in severe TBI takes more than 10 years from dissemination to adoption and that low adherence may be due to barriers such as lack of conclusive recommendations, lack of guideline knowledge, and lack of procedures to implement guidelines. This is problematic because lack of adherence to these guidelines likely results in a high prevalence of secondary insults such as hypoxia and hypotension that are known to adversely affect patient outcomes after severe TBI. Our preliminary data show that the lack of adoption of guidelines for severe TBI and the high prevalence of secondary insults after hospital admission in the U.S. and India are high priority barriers to favorable patient outcomes after severe TBI. Currently, neither JPN Apex Trauma Center in New Delhi, India nor Harborview in Seattle, WA have an interdisciplinary severe TBI pathway, nor is it known if U.S. guidelines can be adapted to international settings. Our project goal is to develop and use a severe TBI adherence scorecard that quantifies adherence to the 2007 Brain Trauma Foundation Guidelines, to examine the prevalence and temporal profile of in-hospital post TBI secondary insults to test the association between adherence to evidence based guidelines and outcomes and to develop an interdisciplinary TBI care pathway that facilitates adherence and improves patient outcomes after severe TBI. The guiding hypothesis is that adherence predicts outcomes and that developing an interdisciplinary TBI care pathway will increase adherence and improve outcomes after TBI. In response to PAR-11-099, we jointly propose 3 Specific Aims as a necessary first set of steps to the long term goal of improving TBI outcomes in both nations: 1) To develop an adherence scorecard that quantifies adherence to evidence based TIB guidelines and examines the prevalence and temporal profile of secondary insults after TBI; 2) To use the adherence scorecard to determine the relationship between adherence to evidence based TBI guidelines and patient outcomes; 3) To examine barriers to adherence of evidence based TBI guidelines and develop an interdisciplinary TBI care pathway that improves adherence, decreases secondary insults and improves outcomes after severe TBI.